However, my first task of the day was to go to the ICU to assess a patient that had just arrived from the Emergency Room. I was called on as the PICC nurse to put a line is him. (For those of you who have no idea what this means or entails I will give you a short description"
- PICC - Peripherally Inserted Central Catheter - Simply, there is an assessment process because it is a bedside procedure of placing a IV line that is about 40 cm long into the upper arm. The line terminates in the SVC (directly above the R. Atrium). It can stay in place for up to a year and run multiple infusions. When people have terrible veins and are very ill they are a godsend. The assessment process included looking at justification for an invasive procedure, infection risks , bleeding risks and possible anatomy issues. I place the line with bedside ultra sound to locate and access the vein and x-ray to confirm placement in the SVC.
My story for today has nothing to do with the situation I ended up in but I thought it might be interesting to let you all know what I do at work these days. I digress.
I walked into the room to find a normal situation. Patient in bed, elderly and ill. He was awake and I greeted him. He was in some discomfort and I new from reading his chart that he was end stage colo-rectal cancer. In the chair next to him was what I assumed to be his wife. She was the one who caught my eye and grabbed my heart. I went to her and could see that she was very tired. I asked her if she had been in the hospital all night. She stated that her neighbor had brought her behind the ambulance after she had called rescue on her husband. I offered to get her some coffee or juice. She leaned forward and rubbed her right knee and asked if I could get her two extra-strength Tylenol because she has arthritis and did not bring any in the rush to get to the hospital. Then I knew I was getting in to a difficult spot. She told me how she did not drive, she was 89 and last time he was in the hospital for 18 days she stayed the entire time. She said she washed up in his bathroom. Of course it is totally against the rules for me to get ANY medication and give it to a patent's family member. But really, how could someone just leave this woman?
I spent 30 minutes going floor to floor and secretaries desk to secretaries desk looking for Tylenol. I ended up with one Tylenol and two Motrin. I knew she probably would not take Motrin (it probably upsets her stomach--which was confirmed when I returned). During that 30 minutes I ran into the charge nurse for the floor and the case manager who know me well from when I worked on the floor. They know how I occasionally get very attached and were not surprised when I voiced my concerns about this woman and her situation. They were looking at me, my sterile garb and saying , but Nicole aren't you a PICC nurse now? Yes, yes but if I don't figure out what this situation is for this woman no one else will and I will feel terrible.
At this time I have no idea if there are children or friends that help her but I thought it would be in her best interest to have it looked into. I did bring her the Tylenol which she took and then let me know that her neighbor was going to bring her other medications for her in the afternoon. I asked her if they loved close by and it happens that they live about an with of a mile from me in a retirement community. I then offered that if she needed a ride home for a shower I would help her. She nodded but did not ask any more.
I went about my day. The patient ended up not needing the PICC line. Other access was established earlier that morning.
In the afternoon I received a text page that the patient in room number ### was not doing well and I might want to stop by. I quickly went to the room. Apparently the nurse taking care of the patient got the impression that I knew this couple very well and would be included in the situation. I informed the nurse that I did not even know their name and had never met them before but felt a strong need and would be happy to help them. The nurse then tells me that the patient is on the max amount of epi (not good) and his pressures are running in the 60's (really not good) and that he signed a DNR earlier that day. The nurse was concerned about he wife who he learned had only been married to the patient for 3 years and was very upset. I asked if there were any children and little was known but I was told that the patient's son was on his way but they did not know when her would arrive.
I walked into the room and went to the side of the patient. He was laying on his side toward the door. He wife was in the recliner behind him on the other side of the room. The neighbor ( a man in his 70's) was sitting next to her. The monitors were on, the room was dimly lit. It was obvious that they did not know what to do. I grabbed the the patient' s hand which was like ice and put it between my hands. I knelt down to his side and he looked at me. I told him that my name was Nicole and I had met him earlier that morning. I smiled at him with sincere gravity and asked him if he was comfortable. He did not say anything but I could see that he was not. I asked him if he was in pain. He said his back hurt. I took one of my hands and held his shoulder and told him not to worry, I would get something for his pain. He believed me and relaxed at the prospect. Next, I went to his wife and and knelt next to her and looked her in the eye and asked her how she was. She told me how upset she was then started talking about the blood pressures. I know they did not mean much to her per say but understood that the physicians communicated the finality of the situation in terms of his low BP's and and the max amount of epinepherine he was already on. I know that low BP meant death and that is what she had as knowledge. I was suprised that the patient was still alert with the pressures he was sustaining.
I asked her if she had eaten today. She told me no, that she couldn't, but she had coffee. I told her that I was going to stay with them awhile and help make her husband comfortable. She seemed happy to have me there and I felt for a moment like I had known this family my entire life. I was caring for my grandmother or grandfather and doing it with experience and grace. The knowledge that I COULD make him more comfortable drove me to do three things. First, I stepped out of the room and asked the nurse if he minded if I got engaged int he process. He looked grateful. He is a great nurse but happens to be very new (still in orientation). I asked about the patient's pain meds and when he was next due and then asked him to call the physician to get him an increase, quickly. Then I made a quick mixture of lotion and Vaseline and warmed it in a Ziploc under hot water. I then asked the patient's wife if she would like to sit closer to her husband (she did) and I moved her chair to the side of his face and put his hand in hers. (In the hospital family are so concerned about getting in the way of the staff that they do not know how and when it is OK to get close to the bed and patient--this was the time to encourage her to do this.) I spent about five minutes on the other side of the bed giving the patient a gentle back rub with the warm lotion.
He relaxed. His next BP reading was 120/70 and sadly I knew the end was near. Sadly, because the wife and neighbor and other nurse thought he was coming back....being cured. This often happens at the end, there is a final surge the body does of being very alert and vital looking really good. This happened right before they finally drop. Anyway, he as comfortable. No more pain medicine had arrived but I was feeling okay knowing that he was settling in. His breathing started to change and I took a deep breath and sat close by with a hand on his back and shoulder. His heart rate began to drop. I could tell he was going. I could also tell that I was the only one in the room who could tell this was happenidng. I gently stroked the patient's head and told him it was okay. At that moment his son arrived. I made eye contact with him and he could tell. I told him to come close and speak to his father, that he was going. He quickly leaned in. His father opened his eyes and the grown son told his Dad that he loved him. He places kisses on his forehead. He began to cry- silently. I looked at the nurse who was at the door and mouthed that he should turn the monitor off. At that point the patient's monitor showed what we all new...asystole. He was gone.
I felt a surge of peace. I felt fortunate to have made him comfortable and to have been present at this most private and important time. I felt honored. The wife still sat there. I realized she did not know. I called her by her name and she looked at me and I told her that he had passed. She wailed and fell into him and my tears came streaming with hers. The neighbor was sobbing and saying what a great man he was and how he had adopted this man as his own father for the past three years. I realized how little I knew about these people. I asked the nurse to call the Chaplain and kept my hand on the passing patient. The patient's wife asked me why I was "rubbing his arm etc" and I felt a little awkward. Did I look like a total nut? I briefly recalled how I did this to my Grandmother this summer when I went to her viewing. She had been gone for over 24 hours and was frozen solid. I still rubber her arms. I guess I did not want the patient (whether in body or spirit) to feel like I would not give them love. I did not want them to think that they were gross or untouchable because they were dead. I feel strongly about that. I could still feel the presence of this man and did not want to cast his temple aside. (Am I being dramatic?--[probably...but these are things I feel strongly about---no matter how strange])
Well, the son gave me hug after I stood at the bedside and took part in a final prayer with the family. I began to realize that I was a nurse and not a part of the family and while I was absorbed and moved I was there to guide and provide structure to the process. I left he room and left them to mourn. I then went to the charge nurse and discussed details with her. Apparently the wife's children were on their way but would not arrive until 6. I asked if she could contact the House Supervisor to see about keeping him in the room until then. Sometimes in the hospital we can move a body within the hour from room to morgue. That always freaks me out a little. Let the body rest people! She said she would see what she could do.
I left the floor, back to the infusion center to take care of the last few patient's of the day. I felt drained and little frustrated with myself. I was able to maneuver myself through that experience with confidence and understanding. This is a feeling I rarely have in my current nursing role. I felt called in a way to that bedside and am frustrated with my inability to persue the calling. I have felt this way at many a final breath over the past four years. I have been given the title of "resident Hospice Nurse" in jest. Yet, I continue to avoid the change or prospect of change to pursue a nursing position in Hospice or Palliative Care.
I am sharing this story with you so that if you speak to me and we are talking about what I should do when I grow up you might remind me that I have skills and a gift in a particular area and at some point it might being me great happiness to utilize them in the workplace.
---Saturday, today was another good day. We had a lazy morning at home. Liam played with a friend int eh afternoon while Hazel and I ran some errands. Then we all went to R's house to celebrate her boys' Birthdays. Liam stayed to spend the night and Hazel and I went to our other friends' house for dinner. We brought Hazel's old Easy Bake Oven and helped their little girl make some cookies ( a big hit). It was a really nice evening. I am blessed with great friends. At home I now have Hazel asleep in my bed and the dogs ready for yet another walk........the cat ready for food and the big dog scooting her bottom across my floor (yuck!) My Florida Room Christmas lights are up! I do still need to start the inside decorating- maybe tomorrow? I am also out of matching socks and comfotable underwear so laundry duty (my least favorite think in this world) is calling my Sunday as well.
--Hazel and I had a good phone call from Lee this afternoon. He is heading out from his current location and should be contacting me from a more permanent base soon. It will be nice to have him settle in and get into some sort of routine. Hopefully with a good broadband connection. Cross your fingers. --
Next morn....call from Lee at his permanent location. He is safe. He has his own room. He will get some sleep and then set up his internet later in the day.
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